01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-07 | 13 | 2025-03-07 | 3 |
| Cycle 2 | 2023-02-18 | 9 | 2023-02-18 | 8 |
| Cycle 3 | 2021-03-08 | 4 | 2021-03-08 | 0 |
CMS CCN 3152762026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Complete Care At Milford Manor Llc
69 Maple Road · West Milford, NJ 07480 · Passaic County
Certified beds120CMS provider file
Recent citation rows37current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
37 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-06-25 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-07-25 · complaint2025-03-07 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-07 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-07 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-07 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-07 · HEALTHF0697Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-07 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-07 · HEALTHF0803Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-07 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-07 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-07 · HEALTHF0883Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-07 · HEALTHF0945Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-07 · HEALTHF0946Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Provide training in compliance and ethics.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-07 · HEALTHF0949Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Correction field: Deficient, Provider has date of correction · 2025-03-102025-03-07 · FIREK0355Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2025-03-082025-03-07 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-03-082025-03-07 · FIREK0914Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Correction field: Deficient, Provider has date of correction · 2025-03-082024-01-05 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-01-26 · complaint2023-02-18 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Correction field: Deficient, Provider has date of correction · 2023-03-312023-02-18 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2023-03-312023-02-18 · HEALTHF0660Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.
Correction field: Deficient, Provider has date of correction · 2023-03-312023-02-18 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2023-03-312023-02-18 · HEALTHF0697Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2023-03-312023-02-18 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2023-03-3103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-03-07 | Fine | $3,595 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- MILFORD MANOR HOLDCO LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 12/27/2021
- PC GC HOLDCO LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 12/27/2021
- SMS 2021 TRUSTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 12/27/2021
- STEIN, SHALOMIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/27/2021
- STEIN, SHALOMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 12/27/2021
- STEIN, SHALOMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/27/2021
- AYDIN, EMMANUELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/27/2021
- REYES, GRACEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/13/2023
- ZACKAI, RAANANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/27/2021
- STEIN, SHALOMIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 12/27/2021
- MILFORD MANOR HOLDCO LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/27/2021
- MILFORD MANOR PROPCO LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/27/2021
- PC GC HOLDCO LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/27/2021
- PEACE CAPITAL HOLDINGS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/27/2021
- SMS 2021 TRUSTOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/27/2021
- AYDIN, EMMANUELIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/27/2021
- REYES, GRACEIndividual · ADP OF THE SNFNOT APPLICABLE · since 03/13/2023
- RUAYA, RIZZAIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/08/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours2.97per resident day
RN hours0.42per resident day
Weekend nurse hours2.44per resident day
Staff turnover53.6%CMS reported field
06 / LOCAL RECORDS
Open the New Jersey ledger →Other published facilities nearby
No second facility in the same city met the directory rule.